The number of people ages 12 to 17 who have been diagnosed with a mental illness in Oregon outpaces the national average, yet Oregon ranks as one of the worst states in its ability to address mental health needs.

Driving the poor outcomes is a dizzying array of problems: the lack of accurate and adequate data to monitor mental health plans and outcomes, chronic workforce shortages in direct care, high staff turnover at the Oregon Health Authority, the lack of coordinated care between state agencies, an inability to track how dollars are being spent and an overall lack of strategy, planning and leadership.

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The latest problems are outlined in an audit released Wednesday from the state’s Secretary of State office, titled “Chronic And Systemic Issues In Oregon’s Mental Health Treatment System Leave Children And Their Families In Crisis.”

The audit might be recent, but many of the problems are not.

Reports dating back 19 years identify similar problems, including Oregon state agencies' inability to coordinate with other agencies and chronic staff turnover.

“High turnover can negatively affect children, especially those who suffer from attachment-related trauma, as direct care staff try to build relationships with children and their support network,” the audit reads. “When the Mental Health Alignment Workgroup issued their report to the Governor in 2001, the group reported 75% of staff in residential treatment programs turn over each year.”

The Oregon Health Authority, or OHA, estimates it will spend $3.2 billion on behavioral health services for the 2019-21 budget cycle alone. The agency’s 2019-21 budget is about $23.1 billion. Yet the agency has failed to define specific goals for behavioral health that could be linked to clear metrics and outcomes, according to the audit.

“Instead, OHA has developed vague, agency-wide goals, such as “Better Health,” linked to high-level performance measures,” the audit reads.

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Auditors say the lack of basic data makes it nearly impossible to understand what mental health services young people received, but also what they need.

“Existing data systems do not include critical information and contain unusable and incomplete data,” the audit reads.

For many children, timely and appropriate intervention could mean they need less expensive and less costly care. Many reports have detailed how Oregon’s inability to offer adequate mental health care has resulted in children being sent to inappropriate levels of care, such as emergency rooms, out-of-state facilities or being kept in motels while in state care.

“... this may result in re-traumatization with lasting adverse effects on a child,” the audit reads.

A huge problem point is the lack of coordination between the state’s child welfare system and the state health authority, two systems that interact with a lot of the same children. The audit uses an example of a 9-year-old boy who was placed in foster care with the state’s Child Welfare program. While waiting for mental health services, the boy spent more than 100 days in a hotel. He was treated in the emergency department and did not have access to regular services and supports. Ultimately, he never received residential care that was recommended and was returned to a foster family setting.

“Given the complexity of Medicaid data and Oregon’s web of service delivery, OHA staff do not have an appropriate mix of expertise to develop a shared understanding of the data analysis guidelines for children and youth mental health services,” the audit reads.

The audit also points out that other states have managed to do better.

“By consolidating authority for children and family System of Care to a single entity, New Jersey has streamlined the coordination necessary for its management,” the audit reads. “As Oregon continues to face chronic fragmentation within its mental health system, especially for children and families, the state may consider some of the steps taken by New Jersey in its path forward.”

Overall, the auditors recommended 22 changes OHA needs to make.

The agency largely agreed.

“The Secretary of State’s comprehensive audit of Oregon’s behavioral health system paints an accurate portrayal of the longstanding shortcomings and failures of our current behavioral health system: lack of common vision, clear outcomes and measures, accountable performance-based contracts, robust data and collaborative stakeholder engagement and public education,” the state’s health authority officials wrote in their response.

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